SEVARON PORADENSTVÍ, s.r.o. Diagnostic Laboratory
Laboratory test request form - cat
SEVARON 4.4/02/01
SEVARON PORADENSTVÍ, s.r.o. Diagnostic Laboratory
BREEDING STATION (owner of the animal) PAYER (owner, veterinarian)
SEVARON 4.4/02/01
SEVARON PORADENSTVÍ, s.r.o. Diagnostic Laboratory
r the owner agrees with all assigned tests and hereby undertakes to pay for them
r the payer agrees with all assigned tests and hereby undertakes to pay for them
Signature: ______
test REQUESted by (owner)______
Name, address:
Telephone: ______E-mail: ______Www: ______
Signature: ______
SAMPLES TAKEN BY (owner, veterinarian)______
Name, address:
Telephone E-mail:
Signature: ______
Date when sample was taken:
Send the result to:
r owner: r E-mail r text message r post r other______
r payer: r E-mail r text message r post r other______
r veterinarian: r E-mail r text message r post r other______
r other: r E-mail______r text message ______r post r other______
Animal species:
SEVARON 4.4/02/01
SEVARON PORADENSTVÍ, s.r.o. Diagnostic Laboratory
r cat
r rabbit
r other……
SEVARON 4.4/02/01
SEVARON PORADENSTVÍ, s.r.o. Diagnostic Laboratory
Reason for test:______
REQUIRED TESTS ____
r BACTERIOLOGICAL TEST:
r ORAL CAVITY / r JOINTS / r EYEr GASTROINTESTINAL TRACT / r SKIN / r RESPIRATORY TRACT
r GENITAL TRACT / r URINE / r EAR
r detection of a specific agent______
r determination of sensitivity to ATB
r MYCOLOGICAL TEST:
r Microsporum canis, Microsporum gypseum, Trichophyton spp. (skin, skin swabs, hair, etc.)
r yeast, Cryptococcus spp., etc. (skin, skin swabs, hair, etc.)
r determination of sensitivity to antimycotics
r PCR TEST ____
r Babesia (EDTA) / r Herpesvirus (swab of conjunctiva, nose, genitals, EDTA)r Borrelia burgdorferi (EDTA, synovial fluid, tick) / r Chlamydophila spp. (swab of conjunctiva, nose, genitals)
r Calici virus (swab of conjunctiva, nose, genitals, EDTA) / r Chlam + Herpes + Calici virus + Mycoplasma (nose, genitals)
r Feline coronavirus (EDTA, feces, rect.swab, body fluids) / r Mycoplasma felis (swab of conjunctiva, nose, genitals)
r FeLV (EDTA) / r Parvovirus (FPV) (EDTA, feces)
r FIV (EDTA) / r Toxoplasma gondii (feces, EDTA, genital swab)
r Haemobartonella felis (EDTA) / r Tritrichomonas foetus (feces)
r IMUNOCHROMATOGRAPHIC TESTS (Ag = antigen, Ab = antibodies) ____
r Cryptosporidium parvum Ag (feces) / r Giardia intestinalis Ag (feces)r Feline coronavirus Ab (EDTA) / r Chlamydophila felis Ag (swab of conjunctiva, nose, genitals)
r FeLV Ag (EDTA) / r blood groups in cats A, B, AB (EDTA, umbilical blood)
r FIV Ab (EDTA)
r SEROLOGICAL EXAMINATIONS (ELISA, Ab = antibodies) ____
r Feline coronavirus - titers Ab (serum, plasma, EDTA) / r Nt - proBNP (plasma, EDTA)r Chlamydophila spp. Ab (serum) / r Toxoplasma gondii Ab (serum)
r GENETIC TESTS______
r Agouti / pattern (cytobrush, EDTA) / r Hair long test (cytobrush, EDTA)r Amber / NFO (cytobrush, EDTA) / r Chocolate/Cinnamon (cytobrush, EDTA)
r Blood Group Test - B allele (cytobrush, EDTA) / r HCM 1 / RAG, MCO (cytobrush, EDTA)
r Coat Color Panel (cytobrush, EDTA) / r HCM 2 / RAG, MCO, BRI, PER, NFO (cytobrush, EDTA)
r Colorpoint Restriction (cytobrush, EDTA) / r PK / Pyruvatkinase def. / ABY, SOM (cytobrush, EDTA)
r Dilute (cytobrush, EDTA) / r PKD (cytobrush, EDTA)
r GM 1/2 / Gangliosidosis / KOR, SIA (cytobrush, EDTA) / r PRA rdAc / ABY, SOM, OCI (cytobrush, EDTA)
r GM 2 / Gangliosidosis / BUR (cytobrush, EDTA) / r SMA / Spinal Mus. Atrophy / MCO (cytobrush, EDTA)
r GSD IV / NFO (cytobrush, EDTA) / r Sphynx and Devon Rex Coat Test (cytobrush, EDTA)
r OTHER TESTS______
r Anti A titer for B blood group (EDTA) / r Pathology and Anatomy exam.r Biochemistry (serum, urine) / r PLI r TLI r B12 r folic acid (serum)
r Hematology (EDTA) / r T4 r fT4 r T3 r TSH (serum)
r Histology (organs) / r E-screen r Grass panel r Tree panel
r Parasitology (feces) / r Allergens – home environment r Malassezia allergen
r Other______
Smp No. / Kind of sample / Name of animal / Breed / color of animal / Gender / Date of birth / Chip / NoteSEVARON 4.4/02/01
SEVARON PORADENSTVÍ, s.r.o. Diagnostic Laboratory
SEVARON 4.4/02/01